Endoscopic Subcutaneous and SMAS Facelift Without Preauricular Scars

Since the advent of endoscopic techniques for facial rejuvenation, we have seen an increasing number of patients asking for facial improvement who refuse a conventional full facelift. During the last 3 years, in seeking to obtain good results for this group of patients with minimally invasive techniques, we have been using a subcutaneous approach for lifting of the mid- and lower face. This subcutaneous temporofacial lift combined with SMAS suspension, which resembles our conventional approach of rhytidectomy but avoids preauricular scars, is an excellent approach for selected cases.     

High-Tech Facelift

Recent technological advances in our specialty have made us reappraise the way we approach facial rejuvenation. Some of these technological interfaces have made it possible, in the author's exerpience, to improve results and to tackle difficult aesthetic problems. The purpose of this paper is to report how we combine these technological advances in an effort to improve the aesthetic outcomes. These technological advances are: laser skin resurfacing, endoscopy, newer fat grafting procedures, and new alloplastic materials for bone augmentation. Other technological advances are consultations via the Internet, computer imaging for simulation of possible outcomes, etc. Endoscopy is routinely used in our facial rejuvenative procedures, almost always for the forehead, often for the midface and less often for the neck. Fat grafting procedures using newly adapted concepts are used for the brow, glabella, tear trough deformity, cheeks, lips, chin, nasolabial folds, marionette lines, and other areas of soft tissue depressions apparent before or after the lifting procedures. This has allowed us to restore the tridimensional volume and treat the soft tissue atrophy. Patients with significant skeletal soft tissue disproportion due to aging, loss of dentition, prior trauma or congenital defects may receive one or more of the following implants: glabella, cheek, piriformis, angle of the mandible, mandibular body glove type of implant, prejawl implant, chin overlay or a glove type of implant. Our preference is for a porous polyethylene material because of its tissue ingrowth inductiveness. Individuals who have damaged skin due to solar exposure, aging, smoking, etc., may receive Ultrapulse CO₂ laser resurfacing at the same operative setting (more often) or in a delayed fashion. The Versapulse laser is also needed for the treatment of some skin changes secondary to aging such as telangiectasias (Variable Pulse Green) and brown spots (Q-Switch 532). The high-tech facelift has allowed us to treat the severely damaged skin, fat atrophy, bone atrophy in many patients, at the same time that the lifting procedure is performed. This provides a more comprehensive approach to facial rejuvenation. The combination of different techniques and technologies maximizes the effectiveness and minimizes the potential side effects of each one. Scars in the forehead and scalp are avoided. Incision and fat removal in the lower eyelid are often unnecessary. It provides a more precise vertical lifting with correction of the tear trough deformity and gives a tridimensional restoration of the facial volume. The facial disharmony is treated at every level starting from the facial skeletal support to the most external envelope (skin). Over 200 patients have been treated this way with a minimal rate of complications. The high-tech facial rejuvenation has allowed us to improve the surgical results of our patients compared with previous isolated techniques. The combination of each one of the techniques require a precise understanding of the limits and benefits of each. Case examples of the different combinations will be shown.     

The Emerging Role of Laser Resurfacing in Combination with Traditional Aesthetic Facial Plastic Surgery

Traditional aesthetic plastic surgery procedures (facelift, browlift, blepharoplasty, etc.) can make dramatic improvement in the facial appearance by removing excess skin and fat and tightening and repositioning the soft tissues of the face, but make no improvement in the quality of the skin. Laser resurfacing is the safest, most predictable method for improving facial wrinkles and actinic damage. This paper discusses the combination of these techniques in pursuit of optimal rejuvenation of the face.     

Liposuction and Surgical Recontouring of the Neck: A Retrospective Analysis

BACKGROUND: With the advent of tumescent liposuction, many advances in cosmetic surgery have occurred. Liposuction of excess adipose tissue from the submental area, jowls, and neck, along with cold steel surgery, has become an attractive alternative to the facelift for cervicomental aesthetic surgery. OBJECTIVE: To describe new techniques for tumescent neck liposuction, platysma repair, and subcutaneous musculoaponeurotic system plication, evaluate results, and assess complications with the procedures. METHODS: We reviewed the results of the last 35 patients who underwent neck liposuction, simultaneous platysma plication, subdermal CO2 laser resurfacing, and/or subcutaneous musculoaponeurotic system plication at our institution. RESULTS: Three of 35 patients (9%) experienced mild complications from the procedure. Two of the three complications (66%) were in patients who underwent subdermal and/or platysma laser resurfacing at the time of liposuction. Good to excellent results were achieved in 91% of patients and fair to good results were achieved in 9%. No major complications such as nerve injury occurred. CONCLUSION: Neck liposuction can be a safe method for facial rejuvenation when performed properly. Platysma repair, and in some cases subcutaneous musculoaponeurotic system plication, can further improve results when combined with the liposuction procedure.     

The S-Lift Facelift Featuring the U-Suture and O-Suture Combined with Skin Resurfacing

BACKGROUND: A short-flap S-lift may be helpful for minor jowling or submental laxity in cases of early facial ptosis, revision facelifts, or where skin resurfacing is combined with neck lifting. OBJECTIVE: To develop a safe and effective method to lift the jowl either as a single procedure or combined with other rejuvenation methods. METHODS: After the induction of monitored anesthesia care the skin resurfacing is completed, if necessary, and the submental and lateral S-lift incisions are marked next to the tragus. The submental area is hydrodissected with modified tumescent solution. After a 15-minute waiting period, the submental area is debulked with small spatula cannulas using reduced pressure liposuction. Often the platysma bands are tied together with a running locked suture. The right cheek area is hydrodissected and debulked in a similar fashion. A 3-4 cm flap is elevated. If necessary, further blunt dissection is passed through the anterior mandible ligament and the nasolabial fold. Care is taken to keep the skin trabeculae intact. The SMAS is plicated with a U-shaped and O-shaped purse-string suture. Following this tightening of the subcutaneous tissue, the skin is closed with a double-layer closure. The face is dressed in two layers of tube gauze. Sutures are removed in 7-9 days. RESULTS: This S-lift gives a pleasing rejuvenation of the jowl and submental area. It is also possible to combine this procedure with other procedures such as corset platysmaplasty, skin resurfacing, fat augmentation, a browlift, or blepharoplasty. CONCLUSION: The S-lift provides a safe and effective method for rejuvenation of the early sagging face or for revision facelift.     

Refinements of minimal-incision rhytidectomy

Minimal-incision rhytidectomy has achieved increased popularity in recent years and is used successfully to rejuvenate the mid-face and submental regions. A technique of minimal-incision rhytidectomy is presented that eliminates post-auricular scarring and hairline distortion without need for a visible dog ear adjacent to the lobule. All dissection is performed through an incision in the temporal hairline and pre-auricular areas. A multi-vector SMAS plication is performed with the addition of submental liposuction and limited laser resurfacing if necessary. Skin excess is distributed into the temporal hair and a downward rotation flap is utilized to eliminate the resultant dog ear. Representative results are presented utilizing this technique which has become the author's preferred method of facial rejuvenation where limited correction of cervical aging is required. With the exception of more limited correction in the mid and lower cervical areas, results are comparable to traditional methods with a more extensive scar burden. The technique presented is applicable to a wide range of patients and may have special utility in male patients and in tobacco users.     

My current options in cervicofacial lift. Results, disappointments and development from 1980 to 1990]

Based on a series of 100 cases of cervicofacial face lift selected at random over a period of 10 years, the author describes the development of her personal technique together with the results and disappointments responsible for this development. She distinguishes 3 surgical periods. The first period (1980-1984) was characterised by very extensive subcutaneous undermining associated with reduced detachment of the facial SMAS, systematic anterior and variable posterior platysmaplasty. The second period (1984-1986) was distinguished by abandonment of the systematic submental approach, a persistent extensive subcutaneous undermining especially in the neck, more pronounced dissection of the facial SMAS and a systematic posterior platysmaplasty. The third period (1986-1990) was marked by a trend toward more limited subcutaneous undermining and more dissection-section-resection-retention of the facial and cervical SMAS and the current tendency consists of total platysmaplasty.     

Subperiosteal minimally invasive laser endoscopic rhytidectomy: The SMILE facelift

Current concepts of total facial rejuvenation involve a comprehensive integrated approach to achieve a balanced youthful appearance. Recently introduced endoscopic-assisted techniques allow us to rejuvenate the face through small, remote incisions. Previously, we have considered only young patients with good skin turgor as candidates for minimally invasive procedures, but the advent of the resurfacing laser has allowed us to expand our indications for single stage minimal access rejuvenation. Full facial immediate laser resurfacing at the time of standard rhytidectomy has been avoided due to risk of flap necrosis. Subperiosteal minimally invasive endoscopic assisted techniques do not substantially interfere with facial blood supply. We can now perform endoscopic-assisted full facelifts combined with immediate laser resurfacing to reposition the tissues in a more youthful position and then tighten the skin envelope. Extended endoscopic-assisted subperiosteal forehead lift is performed through three to five scalp incisions; subperiosteal midface lift is performed through a crow's foot or intraoral incision. Cervicoplasty, if needed, is performed through a small submental incision. Full face laser resurfacing is done using a Coherent Ultrapulse laser. To date we have performed eleven subperiosteal minimally invasive laser endoscopic (SMILE) rhytidectomies. There has been no evidence of flap necrosis with this technique. Postoperative recovery has been no different from patients treated only by full face resurfacing, except perhaps for the slight increase in early facial edema. We believe the SMILE facelift is a viable alternative to standard techniques. The limitations of this procedure still need to be elucidated.     

The subperiosteal bicoronal approach to total facelifting: the DMAS--deep musculoaponeurotic system

Craniofacial surgery, developed by Paul Tessier, has shown that subperiosteal undermining and lifting of the soft tissues of the upper two-thirds of the face results in an excellent and long-lasting rejuvenated look to the entire face. The result is significantly more durable and longer lasting than the classic subcutaneous facelift reinforced with SMAS plication, transposition, and shortening. The authors--three surgeons working independently--are convinced that we have entered a new era in facelift procedures. We decided to combine our experiences which total 250 patients with followups of 6 months to 6 years.     

The subperiosteal bicoronal approach to total facelifting: The DMAS—Deep musculoaponeurotic system

Craniofacial surgery, developed by Paul Tessier, has shown that subperiosteal undermining and lifting of the soft tissues of the upper two-thirds of the face results in an excellent and long-lasting rejuvenated look to the entire face. The result is significantly more durable and longer lasting than the classic subcutaneous facelift reinforced with SMAS plication, transposition, and shortening. The authors—three surgeons working independently—are convinced that we have entered a new era in facelift procedures. We decided to combine our experiences which total 250 patients with followups of 6 months to 6 years.     

除皱术中外耳的处理

目的　在除皱术中通过合适的手术设计和方法，既取得满意的除皱效果，又能防止术后外耳畸形。方法　术前合理设计耳前、耳后切口，术中皮下有限剥离，SMAS下广泛剥离，将颊部松垂组织上提缝合固定的张力放在SMAS层，既有效矫正颊部软组织松垂，又能使耳前耳后切口无张力缝合。结果　1995年至1999年共施行除皱术40例无并发症发生，术后效果满意。结论　除皱术中同时对外耳处理，能取得更加完美的手术效果。     

Observations on a New Concept for Correction of the Nasolabial Fold in Rhytidectomy

Correction of the nasolabial fold has been the challenge constantly faced by the plastic surgeon since the start of attempts at facial rejuvenation. In this paper we intend to show observations which were made in a quite different method of approach to the correction of this challenging anatomic detail. It consists of taking the subcutaneous tissue which forms the nasolabial fold, underneath the same fold, following the law of gravity, without touching or dissecting the superficial aponeurotic muscular system (SMAS) and without using any other artifice which could make it difficult to observe this different procedure. The technique was used on 15 patients who requested facial rhytidectomy.     

除皱术中外耳的处理

目的　在除皱术中通过合适的手术设计和方法 ,既取得满意的除皱效果 ,又能防止术后外耳畸形。方法　术前合理设计耳前、耳后切口 ,术中皮下有限剥离 ,SMAS下广泛剥离 ,将颊部松垂组织上提缝合固定的张力放在SMAS层 ,既有效矫正颊部软组织松垂 ,又能使耳前耳后切口无张力缝合。结果　 1995年至 1999年共施行除皱术 40例无并发症发生 ,术后效果满意。结论　除皱术中同时对外耳处理 ,能取得更加完美的手术效果。     

The Mini Rhytidectomy

A technique is described in which superficial musculoaponeurotic system (SMAS) is plicated from the deep temporal fascia above the zygoma to the level of the earlobe. This procedure requires only an extended preauricular incision. The neck is dealt with by liposuction. This technique is ideally suited to the younger patient requesting facelift and is based on a sound understanding of the anatomy of SMAS. The outcome of 35 patients who underwent this procedure during a 3.5-year period are described. There were no cases of facial nerve paresis or hair loss. There were no cases of skin necrosis but two patients developed small hematomas and one patient complained of a stretched preauricular scar. The mini facelift leads to a satisfactory result in the younger patient requesting rhytidectomy. The technique is simple and safe and can easily be performed on an ambulatory basis. Complications are uncommon and of a minor nature.     

Superextended facelift: our experience with 3,580 patients

Our experience using the "Superextended" facelifting technique in 3580 female patients is presented herein. The technique is based on extended subcutaneous facial and neck skin undermining, extensive superficial musculoaponeurotic system (SMAS) dissection with low lateral freeing of the edges of the platysma muscle. The trimmed SMAS is fixed to the adjacent tissues, enabling the upward and lateral pulling effect of the facial structures. The neck contour is rebuilt by lateral pulling and fixing of the dissected lateral platysmal edges, along the entire neck, and meticulous supraplatysmal fat sculpturing. The skin is redraped over the newly built SMAS and platysmal skeleton, trimmed, and sutured without any tension. The concept of beauty in the eyes of the surgeon is expressed by adding other ancillary procedures during or shortly after the main procedure. Subcutaneous forehead lift using the hairline incision was performed in 70% of the female patients, concomitantly with the face-lifting procedure. Upper and lower blepharoplasties, chin implant, perioral dermabrasion, rhinoplasty, and fat grafting have been performed according to the surgeon's judgment and the patient's request. The objectives of an ideal facial surgery, which are youthful, natural, dynamic, attractive, feminine, and long-lasting results, can be achieved using this technique. Lack of major complications and an overall minor complications rate of only 4.4% makes this technique safe, reproducible, and reliable. This is one of the largest presented series of this procedure, performed by 1 surgeon. The presented cases demonstrate the results obtained using this technique.     

Rhytidoplasty Without Periauricular Scar

As plastic surgeons, it has always been our goal to reduce the scarring associated with facial plastic surgeries. These scars generally occur on the scalp and in both the pre- and retroauricular areas. In 194 of our patients who underwent rhytidoplasties, we successfully eliminated these retroauricular and preauricular scars. To achieve these results, we did not make periauricular incisions; instead, we made a superior incision, a subcutaneous dissection, and used various surgical maneuvers such as subdermal plication and structural grafting. By utilizing this facelift technique, we were able to eliminate the appearance of periauricular scars associated with facial plastic surgery, reduce complications, achieve natural-looking results, and increase patient satisfaction.     

Minimally Invasive Facial Rejuvenation Endolaser Mid-Face Lift

Endolaser mid-face lift was performed on patients in a multi-center study over a 36-month period (Feb. 1998 to Feb. 2001). It permits significant facial rejuvenation through small incisions. This technique achieves aesthetic results and wider rejuvenation while being less traumatic and creating minimal morbidity. Combined with other procedures, it rejuvenates the face by three strategic methods: soft tissue suspension, reversal of photo aging, and correction of the depletion of volume. To achieve this triple result, the mid-face lift is performed by endoscopic approach, and in every case is combined with the endoscopic lift of the frontal area. Laser resurfacing was used to reverse skin photo damage. The Ultrapulse CO₂ laser and/or the Ultrafine Erbium YAG(Coherent, Inc, Palo Alto, CA) were used. The third combined procedure was the introduction of fat graft to compensate the atrophy/ptosis of fat and the depletion of bone mass (other filling materials besides fat may be used, depending on the preference of the surgeon). Our method of fixation using the Casagrande Needle (an evolution of Reverdin Needle) makes the mechanical purchase on the tissues to be suspended much easier, permitting the intra-oral and/or infra-orbital incisions to be eliminated. The present study of the technical evolution of the endolaser mid-face lift method allows us to conclude that a very satisfactory outcome has been reached, offering patients a minimally invasive procedure, which can be performed under local anesthesia, with low morbidity, imperceptible incisions, and an excellent long-term result.     

Lateral SMASectomy, plication and short scar facelifts: indications and techniques

This article discusses removing a portion of the superficial musculoaponeurotic system (SMAS) in the region directly overlying the anterior edge of the parotid gland, called a lateral SMASectomy. Excision of the superficial fascia in this region secures mobile anterior SMAS to the fixed portion of the superficial fascia overlying the parotid. It is a rapid, safe, and reproducible operation, providing the versatility of traditional SMAS flap undermining and the safety and rapidity of SMAS plication in carefully selected patients.     

Improving the Aesthetics of the Cheek Bone Projection During Facial Lifting

This paper shows how one of the flaps of the SMAS, which is normally eliminated during a facelift as excess tissue, can be folded up and used to improve the projection of cheekbone. The improvement of the projection of this facial area enhances the aesthetic result, when the desired aesthetic result is discreet, in rhytidectomy without having to resort to biomedical material or complex surgical techniques. Our technique, which is safe and easy to handle, simplifies this procedure, providing a long-lasting satisfactory result for both the patient and the surgeon. Our report was done following rhytidectomy on 126 female patients and after an approximately 3-year follow-up.     

Anatomical Study on the Temporal Fascial Layers and Their Relationships with the Facial Nerve

The recent application of endoscopic techniques in facial rejuvenation has stimulated a new interest in the anatomy of this region. In endoscopic face lift, as in open techniques, one of the main steps is the conjunction of dissections of the upper and midface without damage to the frontal branch of the facial nerve. This article provides an accurate account of the organization of the temporal fascial layers and their relationship with the facial nerve. The authors' dissections confirm that the frontal branch, despite the variations in branching patterns, has an anatomical relationship with the surrounding fasciae that can be deemed constant and predictable: The frontal branch lies in the deep layer of the fatty tissue interposed between the suprazygomatic extension of the superficial musculoaponeurotic system (SMAS) and the superficial leaflet of the temporal aponeurosis. The arrangement of the temporal fasciae on the zygomatic arch is also discussed.